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Dreaming of Sleep: The Challenges and Benefits
Muna IrfanAssistant Professor
Department of Neurology, University of Minnesota
Program Director of Sleep Medicine Fellowship, HHC
Medical Director of Sleep Services VA
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Goals
• To provide introduction to sleep, its function and common sleep disorders
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Objectives
• To understand the changes in sleep with age• To identify common sleep disorders
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Driving Question
• How to move the needle on sleep health and wellness in our communities?
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Driving Question
• Unique Features of Sleep Medicine
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Driving Question
• Unique Features of Sleep Medicine1. Most Evidence Based Therapies are Non-Pharmacological.
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Driving Question
• Unique Features of Sleep Medicine1. Most Evidence Based Therapies are Non-Pharmacological.
In contrast to Neurology, for example
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Driving Question
• Unique Features of Sleep Medicine1. Most Evidence Based Therapies are non-pharmacological.2. Solutions Require Knowledge Transfer
In Contrast to Pneumonia
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Driving Question
• Unique Features of Sleep Medicine1. Most Evidence Based Therapies are non-pharmacological.2. Solutions Require Knowledge Transfer
In Contrast to PneumoniaSleep Medicine Fellowship Experience
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Driving Question3. Sleep solutions are relatively easy to
implement.
Contrast… Obesity where the answers are obvious but extremely difficult in practiceSleep solutions are often paradoxically difficult to understand but then once understood they are (relatively) easy to implement
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Driving Question
• How to move the needle on sleep health and wellness in our communities?
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Driving Question
• How to move the needle on sleep health and wellness in our communities?
1. Explain in a compelling and customized manner the importance of sleep.
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Driving Question
• How to move the needle on sleep health and wellness in our communities?
1. Explain in a compelling and customized manner the importance of sleep.
2. Knowledge transfer sleep conditions
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Driving Question• How to move the needle on sleep health and
wellness in our communities?
1. Explain in a compelling and customized manner the importance of sleep.
2. Knowledge transfer sleep conditions
3. Knowledge transfer sleep solutions
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ContentsIntroduction to Sleep
Some functions and consequences of inadequate sleepSleep in agingMotivating the audience to improve their sleep
Sleep DisordersCan’t Sleep, Too Sleepy, Weird Things
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Importance of SleepCDC study
correlated sleep with happinesscontrolled for education, income, employment
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Sleep and the Health of the Brain
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Sleep Maintains Healthy Brain CellsNeurons:
• 100 billion neurons
Synapses:• 100 trillion synapses
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Recent Breakthrough: CNS Metabolite/Toxin Clearance
• 2012 breakthrough
• Sleep Serves to clear out toxic metabolites from the brain
• Clears beta-amyloid (Alzheimers, Concussions) pathology
(Xie 2013, Lucke-Wold et al 2015)
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©2016SleepPerformanceInstitute
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Sir Paul McCartneymelody came to him in a dream
Felt so familiar he assumed that he had merely remembered it.
Was very concerned he was subconsciously plagiarizing.
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Sir Paul McCartney“For about a month I went round to people in the music business and asked them whether they had ever heard it before. Eventually it became like handing something into the police. I thought if no-one claimed it after a few weeks then I could have it.”
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Sleep and its functions
GrowthImmune functionBrain developmentSynaptic homeostasisMemory Unlearning theoryGlymphatic system
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Sleep Cycle
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Sleep StagesNREM sleep
• N1 (lightest)
• If awoken, most would not even believe
• Drop in Body Temperature
• N2 (Intermediate)
• OSA, Seizures
• N3 (Deepest Sleep)
• Most Refreshing Sleep
REM Sleep• Brain Activity similar to
wakefulness
• dreams
• Skeletal muscle paralysis
• Relatively light stage of sleep (ie very easy to awaken out of)
• Ectothermia
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Sleep & AgingNSF recommends 6><9 hrs of sleep with• better cognition
• mental health
• physical health
• quality of lifeMiner B, Kryger MH. Sleep in the Aging Population. Sleep Med Clin. 2016;12(1):31-38.
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Sleep & Aging
PerspectiveNeurobiology of Sleep and Microbiomics in Aging
Larson-Prior 2017
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CHANGES IN SLEEP ARCHITECTURE:
Most by 60 except sleep efficiency continues to decline 90 & beyond
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CHANGES IN SLEEP ARCHITECTURE:
PHASE ADVANCE:
• Earlier onset of sleep in the evening
• Earlier morning awakening
NAPPING
• mixed results
MANAGEMENT
• Medical, psychiatric, and psychosocial factors
• Approach as multifactorial geriatric health condition
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NREM/REM Cycle
Cat in NREM
Ca
Cat in REM
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Sleep Education
• Sleep Disorders are:• Common, Distressing
• Numerous comorbidities/early mortality
• Suboptimal Sleep is nearly universal
(National Sleep Foundation-2014 Sleep in America Poll)
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Sleep and Performance in the Workplace
• presenteeism• absenteeism• Poor
productivity
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Acute Consequences• Daytime sleepiness• Slow reaction time• Poor memory
• Poor judgment• Irritability• Distractibility
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Chronic Consequences
• Obesity• Heart disease• Diabetes• Cancer• Dementia• Depression and
mood disorders• More to Come…
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Sleep Education: Motivating the Audience
Get a new approach
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Sleep Education: High Performance Athletes
• Great interest in optimizing neurological performance
• Ruthlessly objective
• A 5-8% improvement in brain processing speed can have dramatic changes in outcome
ABC Sports(Winter et al 2009, Venter 2012,
Thun et al 2015)
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Roger Federer11-12 hrs
Lebron James12 hrs
Usain Bolt8-10 hrs
Sleep Routines
(Abrams 2011, McCann 2012)
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Controlled Study Using Golfers recently diagnosed with OSA
Correction with CPAP resulted in a mean drop in handicap from 12.4 to 11.0
Greater response amongst skilled golfers
9.2 to 6.3
(Benton et al 2013)
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Review of Sleep Problems
I. Can’t fall asleep
II. Too sleepy during the day
III. Something weird is happening during sleep
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Can’t Fall Asleep• 30% of adults will describe some difficulty falling
asleep annually
• One third (10% total population) have daytime dysfunction
• 5.5 million office visits (US)
• Sedative Rx
• 1999-5.3 million
• 2010-20.8 million
(Roth 2007, Ford et al 2014)
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I. Can’t Sleep
1. Circadian (night owl, morning lark)
2. Restlessness3. Mind won’t shut off (Overactive brain)
The Three Causes
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Galileo spacecraft-NASA
Modern problem
Two Causes• Evening exposure to lights• Relative absence of morning sunlight
Circadian (Biological clock) Delay
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Can’t fall asleep and hard to wake up“I go to bed at 11 pm. I lay in bed trying to sleep, but
my brain will not shut down. It takes me at least an hour (sometimes several) to
fall asleep”
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Can’t fall asleep and hard to wake up
“Once I fall asleep, I will usually sleep well until the alarm goes off, but then I
need to hit the snooze button. I could sleep a lot longer”
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CIRCADIAN DELAY
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CIRCADIAN DELAY
• THIS
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CIRCADIAN DELAY
• THIS IS
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CIRCADIAN DELAY
• THIS IS NOT
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CIRCADIAN DELAY
• THIS IS NOT AN OVERACTIVE BRAIN!!!
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CIRCADIAN DELAY
• THIS IS NOT AN OVERACTIVE BRAIN!!!
• YOU DO NOT NEED A PILL FOR THIS
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CIRCADIAN DELAY
• THE GOAL IS TO SHIFT YOUR SLEEP TIMING
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Circadian Delay Protocol
1st thing to do-sunlight or 10,000 lux light exposure 30-120 minutes in AM2nd thing to do-low dose 0.5-1mg melatonin 2-6 hours prior to bedtime (some flexibility)3rd thing to do…
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Circadian advancement
Early morning awakening• Light before bedtime• reassurance
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Restlessness“I lay in bed and I can’t get comfortable. I feel like I could fall asleep, but I can’t because of this urge to rollover, adjust position, get up and walk…… If it wasn’t for these sensations I could fall asleep”
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RestlessnessYou have restlessness if you answer yes to the following questions
1. Do you have discomfort at night?2. Does this discomfort compel you to move?3. Does movement make it better?4. Does this interfere with your ability to sleep?
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Restless Legs Syndrome-The Vexing Syndrome
• Symptoms often vague or difficult to describe
• Often only history given is “I cant fall asleep”
• The discomfort they do feel is often misattributed to some other diagnosis
• “Oh that’s just my back pain”
• “That’s my diabetic neuropathy”
• “I get anxious at night”
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Non-Motor Symptoms• Restless Smoking
• Patients will describe a need to smoke in order to “calm down and fall asleep”• Smokers without RLS do not describe this experience
• Restless Eating• urge to eat, not driven by hunger but instead a perception that
eating will make it easier to fall asleep
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Restlessness
• THIS IS NOT AN OVERACTIVE BRAIN!!!
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Restlessness
• THIS IS NOT AN OVERACTIVE BRAIN!!!
• YOU DO NOT NEED A SLEEPING PILL FOR THIS
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Restlessness
• THE GOAL IS NOT TO
“SHUT DOWN YOUR BRAIN”
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Restlessness
• THE GOAL IS TO ELIMINATE THE RESTLESSNESS THEN YOU SHOULD NATURALLY FALL ASLEEP
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Overactive Brain
“I go to bed and my mind won’t shut
down”
“I am constantly waking up for
prolonged periods atnight”
“When the alarm goes off in the morning, it is a relief because I can now
get out of bed”
“I am exhausted during the day but I
cannot nap”
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What About Sleeping Pills?
• Commonly prescribed (zolpidem, eszopiclone..etc)
• Sleeping Pills have concerning adverse side effects.
• Only modest improvement on objective sleep efficiency
• Primarily improve subjective sleep efficiency
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An Example of a Patient Prescribed a Sleeping
PillPre Treatment Post Treatment
Subjective Sleep Efficiency
40%Objective Sleep Efficiency
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An Example of a Patient Prescribed a Sleeping
PillPre Treatment Post Treatment
Subjective Sleep Efficiency
40%Objective Sleep Efficiency
66%
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An Example of a Patient Prescribed a Sleeping
PillPre Treatment Post Treatment
Subjective Sleep Efficiency
40%Objective Sleep Efficiency
66% 75%
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An Example of a Patient Prescribed a Sleeping
PillPre Treatment Post Treatment
Subjective Sleep Efficiency
40% 95%Objective Sleep Efficiency
66% 75%
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Best Therapy for an Overactive Brain…
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Best Therapy for an Overactive Brain…
Cognitive Behavioral Therapy for InsomniaCBT-I
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Can’t Sleep Management Review
• Once circadian delay and Restlessness have been RUTHLESSLY excluded...
• pursue CBT-I
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Sleep Cycle
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Excessive sleepiness
• MOST COMMON CAUSE?
• Sleep Deprivation (or mistiming)
• Sleep Disordered Breathing
• Narcolepsy
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Excessive sleepiness
• MOST COMMON CAUSE?
• Sleep Deprivation (or mistiming)
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Excessive sleepiness
• MOST COMMON CAUSE?
• Sleep Deprivation (or mistiming)
…Sleep MD anecdote
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Conclusion
sleep is fascinating and importantsleep disorders are common, frequently misdiagnosed, and most importantly treatable
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Conclusion
http://etc.ch/LPpt
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Thank you